SMITH AND NEPHEW TOTAL KNEE REPLACEMENT

Another Knee Replacement from another surgeon. Again these is how I observed and experienced on scrubbing with this surgeon. She might be changing it a little bit, but mostly this is how she does it.

It’s been what 3 years now that I’m working for the Neuro people but hey I still remember t o play with the ortho instruments. =)

PROCEDURE	TOTAL KNEE REPLACEMENT
POSITION	Supine with 2 TKR leg holder
EQUIPMENTS/ACCESSORIES	Torniquet Machine Suction Machine X 2 (1 for cementing) Diathermy Machine Kendall SCD Machine Leh Holder
SKIN PREPARATION / PHARMACEUTICALS	Povidone Iodine with alcohol Hexodane (use for prepping after cutting of stockinette) 10% Povidone with 10% Alcohol 3L Normal Saline for washing using surgilav
INFILTRATION	Refer To Doctors Cocktail Dilution
DRAPES	Disposable Extremity Drape ABD Pack – placed under the knee during suturing and washing Extra-Extra ABD sheet (use to cover all the trolleys before pushing inside OT)
STEPS IN DRAPING	Loose ABD Sheet U-Drape from the set Dressing Towel to hold the leg Stockinette (loose) 6 inches Elastic bandage Extremity Drape (with hole in the center) Green Sticky Tape from Extremity Drape Utility Scissors (orange handle) to cut stockinette Ioban
INSTRUMENTS SETS / SUPPLEMENTARY SETS / LOOSE INSTRUMENTS	SETS: Ortho Basic Set General Basin Set Ortho Large Lambotte Osteotome Set ·       Osteotome Straight 13mm, 20mm, 30mm ·       Osteotome Curved 20mm Ortho TKR Supplementary Set SS Tray LOOSE INSTRUMENTS: Light Handle Medium Quiver x 2 Big Straight Rongeur Tibial Wedge Clamp (loose inst. Placed on Dr. Ho totebox) Cobbs Elevator (small) s/b Narrower Tip Nibbler (small) s/b
SUPPLIES / CONSUMMABLES	Diathermy Hand Control Diathermy Scrapper Suction Tubing Yankuer Suction x 2 Tegaderm X 2 (to seal the hole from disposable suction tip) Raytex Gauze, Penny Towel, Plain Gauze Syringe 50 mls Blade 10 x 5 Pulsavac Zimmer Ioban 6650 Needle G23 (green) x 3, Needle G19 (pink blunt needle for tranexamic) Orthoban X 2 6 inches Crepe Bandage X 2 Black Spinal Needle x 2 – S/B Zimmer Mixi-Gun with short nozzle Tranexamic Acid 500mg – 1.5gm needed Gel Knee Wrap on op site after surgery Surgical Marker x 2 (one will pass out after using to mark the skin)
SUTURES	Vicryl 1-0 (cutting) x 1 - muscle Vicryl 2-0 (cutting) x 1 – fascia Monocryl 3-0 (cutting) x 1 - skin Stratafix round body x 2 (ref#:SXPPIA404) – skin Dermabond Prineo – to open when skin closure is finishing (to prevent hardened of the glue)
DRESSING	Opsite L x2 Plain Gauze 6 inches Orthoban
	6 inches Crepe Bandage x 2
REMARKS	1.     Hexodane and Hand Towel to clean the leg first before prepping the patient. 2.     Prepare 250mls of Normal Saline + 9mls of Plain Povidone to be use after implanting (washing) 3.     Use basin during washing of the knee 4.     Bone Cement: J&J Smart Set x 2 5.     During application of implants, wet osteotome straight 20mm for tibia and osteotome curved 20mm for femur. 6.     Intra-op Kendall Cuff on non-op leg. 7.     Once implanting remove all the power tool to mayo table and replace with the necessary intruments use for implanting. 8.     Fresh chlorhexidine in clean gollipot 9.     Post-op: kendall cuff to be place first before applying gel knee wrap 10.   Mayo Table to be on surgeon sides.

   

TKR COCKTAIL DILUTION

(total of 5 syringe 20mls each syringe)

DRUGS/CONCENTRATION	DOSE	REMARKS
1. ADRENALINE 1:1000	0.5ml
2. Morphine 10mg/ml	0.2ml	- to omit if patient had renal impairment . - confirm with surgeon - get from the AU staff and return the remaining balance to them (AU).
3. Ropivacaine 1% (200mg/20ml)	15mls (150mg)	Check with anesthetist the dosage/amount, if patient having block
4. Vancomycin 500mg x 2	1 gram (1000mg)	- check if patient has an allergy - to dilute 5mls of normal saline each vial (you may use 5mls NS from the one you take out from the 100mls 0.9% NS)
5. Normal Saline 0.9%	75mls
6. Ketorolac 1ml/30mg	1ml/30mg	- give 1 ampule - for non-asthmatic patient
7. Shincort (triamcinolone acetomide)	50mg/5ml	- for non-diabetic patient - 20mls each from the diluted cocktail add 2.5mls shincort each syringe - to give first

REMARKS:

1.     Inform the anesthetist first before making cocktail

2.     Check for patients allergies

3.     Use green needle (spinal needle black standby)

4.     Make sure to handover the balance of CD Morphine to AU Nurse for proper disposal and documentation.

INSTRUCTIONS:

1.     Mixed all the medications into 75mls normal saline

2.     Sites to be injected:

a.     Patella fat pad

b.     Femur – anterior periosteum

c.      Femur – posterior periosteum

d.     Medial collateral ligaments

e.     Quadriceps muscles

3.     The above procedure to be done before cementing .

4.     Will not use or do not prepare for revision cases.

5.     Use other alternative antibiotics if patient is allergic to penicillin, confirm this with the anesthetist.

6.     +/- nerve block

7.     On PCA (patient controlled analgesia) x 1 day.

8.     Do not use spike in preparing the cocktail.

commonly instrument use for Smith and Nephew TKR

TOTAL KNEE REPLACEMENT

Procedure: (again this may vary from the surgeons mood=) and patient bone structures or severity of bone deform)

11. First knife to cut the skin.

22. Second knife or inside knife.

33. Retractors (langenback) 3^rd assist surgeon will help to suction the op-site while the surgeon is cutting)

44. Surgeon might use diathermy and lanes forceps for hemostasis or use for cutting of tissues.

56. Inside knife to remove fat tissues until femoral bone totally expose.

67. Long threaded pins/drill

78. Femoral Jig + 2 short threaded pins

89. Checker to give separately (the battery) + screw driver

910. Second femoral jig + 2 long pins on power (2nd femoral jig seen in number 8)

111. Pin remover (drill)

112. Remove the first jig (remaining top jig)

113. Angel Wing

114. Saw

115. Pin puller after sawing

116. Ochsner x 2 to secure the pins for cutting the jig

117. Saw

118. Standby water to irrigate the sawing bone

119. After cutting the bone out remove the the cutting jig (pin puller to pull the pins out)

120. Bone rongeur to remove the ostophytes

221. Marker Pen + Broad big osteotome (use as a ruler to mark the point where she will put the sizer)

222. Sizer + long pins followed by Stylus. (listen to what size the femoral implant is) 

223. Drill Pins (to remove the pins and the sizer)

224. Femoral cutting jig (take the size in which taken when sizing the bone)

handle (attached to femoral cutting jig)

femoral cutting jig (example size 4)

223. Angel wing

224. X 3 long pins + saw

(Prepare the femoral trial to connect it to femoral handle or impactor while the surgeons are busy cutting the femoral bone)

femoral trial should be same size of the femoral cutting jig

225. Pin puller

226. Extractor to remove the cutting jig

227. 25mm Osteotome

328. Ochsner or rongeur to remove or pull the bones while diathermizing it.

(femoral prep done)

329. Double prong to lift the femoral bone while prepping the tibial bone

330. Tibial jig + Mallet

tibial jig

331. Short threaded pins x 2

332. Rubber to secure the tibial jig from patient leg

533. Monitor or the checker 

334. Out the top part of the jig + give the man in a boat

335. 2 long threaded pins x 2 (standby 2 retractor)

336. Angel wing

337. Out the checker

438. Ochsner to attached to pins before sawing

439. Saw

440. Pin puller (remove the tibial jig)

441. Tibial wedge to place on the cutted tibial bone (use in pulling the cutted tibial bone while diathermising it. If no use she might ask for rongeur or ochsner in pulling the bone). – once the tibial bone is out you might check the size of it using the the tibial plate usually for male patient size 4-5 and female is 2-4 seldom of having 1.5

442. Small homman (narrow) + Lagenback

443. Laminar Spreader (to spread or separate the femoral bone to tibia)

445. Blade, osteotome, curette, rongeur (to remove the excess bone or osteophytes from the femur and tibia.

446. Pin puller

447. She might ask for the retractor (double prong, homman, lagenback)

448. Spacer block (to check thickness of the insert)

9mm spacer block (black) if needed to add thickness give the grey one.

549. Prepare the tibial plate and insert (according to the patient tibial bone size)

550. Femoral Trial + mallet

551. Bristol to standby (for removal of tibia trial)

After Trial preparation of Patella

552. Patella cutting jig

553. Sizer + saw

554. Rongeur to remove the excess bone or for filling of bone

555. Patella clipper

556. Patella drill

. 57.  Patella trial which come in sizes too.

Once the patella is done she will remove the the femoral and tibial trial

5
558. Femoral Punch

659.  Extractor to remove the femoral trial

660.  Remove the tibial trial

661.  Double prong

662. Tibial plate (size of the patient)

663. 2 long pins + mallet

664. Fat drill

665. Brooch / mallet

666. Extractor to remove the brooch

667. Pin puller to remove the tibial plate

Prepation for tibial bone was done. surgeon may wash the knee with 3 liters normal saline using pulsivac. The scrub nurse then will the implant and mixing of the cement.

Cement use: (depends on surgeon preferred use)

1.     Smart set cement x2

Tools in mixing of cement (depends also on surgeons preference or if the scrub nurse knowledgibility in using mixing cement)

1.     Zimmer mixigun

After washing the knee the surgeon then will infiltrate mix cocktail on patient knee

(refer to cocktail mix)

Once all ready in placing the the final implant to patient prepare the following and place near the surgeon

1.     femoral implant + femoral punch (surgeon will place cement surrounding the implant)

2.     tibial implant + Tibial punch (surgeon will place cement surrounding the implant)

3.     patella implant (scrub nurse will place cement surrounding the implant make sure not covering the 3 dotted thingy on the implant (aha)

4.     insert + inserter

5.     Forceps and Mcdonalds in removing the excess cement

6.     Small osteotome standby

668.  Retractors (lagenback or homman once inserting all the implant).

769.  Closing start to count all your sharps and sponge

Use for closing
             1. Stratafix 1-0 round body x 2
             2. Vicryl 1-0

 3. Vicryl 2-0
 4. Stratafix 3-0 x 1

 5. Dermabond

770.  final counting

771.  Dressing Opsite L x2